Diagnosis, and anti-mullerian hormone (amh) administration for treatment, of infertility for good-, intermediate- and poor-prognosis patients for in vitro fertilization in view of logistic regression models

ABSTRACT

Method of diagnosis of IVF viability. The method includes ascertaining a subject&#39;s AMH level from testing and then selecting one pregnancy or live birth prognosis category that applies to the ascertained AMH level by matching the ascertained AMH level with an applicable one of a plurality of ranges of AMH levels pertaining to an age of the subject. The matching indicates the prognosis category that applies, i.e., (that is, good, intermediate or poor. In view of the diagnosis, a method of administration of AMH may be pursued to increase probability of pregnancy or live birth chances. Alternatively, the administration of AMH may be at AMH levels that will terminate pregnancy or increase the chance of miscarriage.

REFERENCE TO COPENDING PATENT APPLICATIONS

U.S. Provisional patent application No. 62/128,127 filed Mar. 4, 2015.

BACKGROUND OF THE INVENTION

Field of the Invention

The invention relates to categories of good, intermediate and poorprognosis for in vitro fertilization (IVF) according to age of acandidate for IVF. By ascertaining the anti-Müllerian hormone (AMH)level for such a candidate with conventional testing, a diagnosis, andthen therapy, in accordance with the invention may be made as to theprognosis category that applies for pregnancy probability, live birthprobability or both by matching the tested AMH level with an applicableone of ranges of AMH levels of the prognosis categories incorrespondence with the age of the candidate.

The invention then specifically relates to the administration of AMH inview of the logistic regression models that so classify patients orsubjects into the good-, intermediate- and poor-prognosis groups orcategories. Patients or subjects can be classified into good-,intermediate- and poor-prognosis categories based on clinical pregnancyand live birth rates, using only age and functional ovarian reserveparameters. AMH is expressed by a specific category of follicular cellscalled granulosa cells of preantral and antral follicles during thereproductive age. AMH acts as a natural follicular gatekeeper limitingfollicle growth initiation and maintains the primordial follicle poolthroughout the reproductive age.

AMH is also known as a Müllerian inhibiting substance (MIS) and is amember of the large transforming growth factor-beta (TGF beta) family ofglycoproteins that are involved in the regulation of growth anddifferentiation. This family includes AMH agonists, derivatives andother TGF beta agents.

Description of Related Art

The contents of U.S. provisional patent application No. 62/128,127 areincorporated herein by reference pertaining to preparation of acomposition having AMH and its administration to a subject. Further, theentire subject matter under the heading “Definitions” of thatapplication are incorporated herein by reference. Furthermore, the termAMH as used in this application includes AMH agonists, AMH derivativesand other TGF beta agents and MISs.

An AMH test may involve taking a blood sample from the subject in aconventional manner and analyzing the blood sample with appropriateconventional laboratory test procedures and equipment. Laboratory testprocedures and equipment to ascertain an AMH level are conventionallyknown. For example, the Becknman Coulter Diagnostics Access AHM Assaymay be used in an analysis to ascertain the AMH level of a subject.

For this invention, AMH was assessed with such Generation II (secondgeneration) assays. Those skilled in the art will understand that othergenerations of assays and conventional test procedures could be used aswell. While AMH assays may vary at the extremes of very high or very lowAMH levels, they are very similar in the medium and other rangessignificant for this invention and application. As will be disclosed,the previously unknown and undisclosed ‘best’ AMH ranges of significancefor this invention are similar regardless of the assay used.

What establishes outcome prognoses for infertile women entering IVFcycles is not well defined. That is, IVF cycles currently cannot bereliably prognosticated. The ability to reasonably predict prognoseswould be, therefore, clinically valuable. It also would also enhanceinternal as well as external quality controls, the latter being mandatedin the U.S. by an act of Congress and currently not satisfactorilyaccomplished.

Finally, treatments may demonstrate different levels of efficacy ingood-, intermediate- and poor-prognosis patients. Better definition of“disease” severity, therefore, should improve individualization of IVFtreatments.

Prognostication of IVF outcomes has been a longstanding goal. Variousmodels have been published, with the key component being female age, asdeclining clinical pregnancy and live birth rates with advancing femaleage demonstrate. Therefore, changes in outcomes with advancing femaleage have to be considered when building prediction models for IVF.

Age is, however, not the only important predictor of IVF outcomes.Functional ovarian reserve (FOR), a term reflecting the growing folliclepool, and, therefore, oocyte and embryo numbers, is also closelyassociated with IVF outcomes. Abnormally low FOR (LFOR) is defined byabnormally increased age-specific follicle stimulating hormone (FSH)and/or decreased age-specific AMH, both reflecting declining egg andembryo numbers and, therefore, deteriorating pregnancy and live birthchances.

In women with premature ovarian aging (POA), also called occult primaryovarian insufficiency (oPOI), normal statistical associations betweenage and FOR are disturbed. POA/oPOI patients prematurely demonstrateLFOR. They, independent of race and ethnicity, represent approximately10% of females and often more than half of all patients in IVF centers.FOR—rather than age-based models may, therefore, be preferable in POApatients.

Protocols for administration of AMH to women and girls have beenproposed.

Average serum AMH is approximately 4 nanograms/milliliter (4 ng/ml) inhealthy young women with normal ovarian reserve. Kelsey T W, Wright P,Nelson S M, Anderson R A, Wallace W H. A validated model of serumanti-mullerian hormone from conception to menopause. PloS one 2011;6:e22024.

The half-life of AMH is 27.6 hrs. Griesinger G, Dafopoulos K, BuendgenN, Cascorbi I, Georgoulias P, Zavos A, Messini C I, Messinis I E.Elimination half-life of anti-Mullerian hormone. The Journal of clinicalendocrinology and metabolism 2012; 97:2160-2163.

A time period of 90-120 days is the approximate time from primaryfollicle recruitment to ovulation. McGee E A, Hsueh A J. Initial andcyclic recruitment of ovarian follicles. Endocrine reviews 2000;21:200-214

For women with low ovarian reserve who are pursuing controlled ovarianhyperstimulation (COH) for fertility treatment, there is a proposedprotocol.

The proposed protocol is pretreatment with AMH prior to COH and isintended to improve follicular synchrony, oocyte yield and pregnancyrates with fertility treatments. Starting dose of AMH is 4 to 8 ng/mldaily×typical volume (5,500 ml)=22,000 to 44,000 ng/day for 90 days. Thedose and duration may require adjustments based on future studies,patient size as well as other parameters. This treatment would befollowed by a short washout period ranging from days to weeks. The shortwashout period would be followed by controlled ovarian hyperstimulation(commonly used agents include: gonadotropins, selectiveestrogen-receptor modulators, and aromatase inhibitors) and thenfollowed by either Intrauterine Insemination or Oocyte Retrieval for InIVF or for Oocyte/Embryo cryopreservation.

For women and girls who are pursuing fertility preservation due toimminent exposure to gonadotoxic treatments, there is a further proposedprotocol.

The further proposed protocol is treatment with AMH prior to andcontemporaneously with gonadotoxic treatments and is intended todecrease activation and recruitment of primordial follicles via aso-called “burnout” effect, which induces rapid and often complete lossof ovarian reserve via follicle depletion. Recruitment adds follicles tothe pool of so-called growing follicles, which, in contrast toprimordial follicles, are very sensitive to damage from chemotherapydrugs and/or radiotherapy. Kalich-Philosoph L, Roness H, Carmely A,Fishel-Bartal M, Ligumsky H, Paglin S, Wolf I, Kanety H, Sredni B,Meirow D. Cyclophosphamide triggers follicle activation and “burnout”;AS101 prevents follicle loss and preserves fertility. Sciencetranslational medicine 2013; 5:185ra162.

By preventing follicle activation, AMH potentially protects the gonadsfrom chemotherapy and radiation therapy by keeping follicles atprimordial stages, where they are less sensitive to damage, therebypreventing loss of fertility as a consequence of gonadotoxic treatments,as currently seen in cancer patients and in other medical conditionsrequiring such treatments.

The starting dose of AMH is 4 to 8 ng/ml daily×typical adult volume(5,500 ml)=22,000 to 44,000 ng/day. Dose and duration may requireadjustments based on future studies, patient size as well as otherparameters. Lower doses may be appropriate for pediatric patients.Treatment with AMH is initiated several days prior to and continuedduring gonadotoxic treatment, AMH should be continued until gonadotoxictreatment is stopped.

There is a need to understand the affects of AMH levels on pregnancyrates, birth rates and miscarriage rates sufficient to administer AMH ina manner to control such rates. There is no basis in the prior art tocontrol AMH at certain levels, as opposed to simply increasing AMHlevels, in order to promote candidacy for IVF and/or to increasepregnancy, live birth and/or miscarriage rates. If such administrationwould be to achieve and/or maintain a certain AMH level, regardless ofother hormones such as FSH and other treatments, an entirely new area oftherapeutic utility for AMH would be disclosed and taught. This, inpart, is the subject matter of this invention.

SUMMARY OF THE INVENTION

One aspect of the invention relates to the administration of AMH basedon classification of patients at all ages prospectively as well asretrospectively into good-, intermediate- and poor prognosis for invitro fertilization.

The classification arises by establishing, for all ages, definitions ofgood, intermediate and poor prognosis patients based on clinicalpregnancy and live birth rates. Utilizing three, mostly overlappingpatient cohorts, logistic regression models can be established withpredictive of age-specific clinical and live birth rates based on threedifferent functional ovarian reserve (FOR) parameters (good qualityembryos, FSH and AMH).

Indeed, all three models at all ages allowed clear separations of good-,intermediate- and poor prognosis patients, though definitions changewith age. In each age category, with transfer of similar embryo numbers,clinical pregnancy and live birth rates almost consistently improvedwith growing embryo production, although completely unaffected by embryoquality, as defined by pregnancy loss (i.e. mostly aneuploidy). Whileembryo and FSH models demonstrate almost linear associations withdecreasing FSH and increasing embryo production, the AMH modeldemonstrates a bell-shaped polynomial pattern of association, withhighest clinical pregnancy and live birth rates at mid-range. This“best” AMH level was associated with unexpectedly high clinicalpregnancy and delivery rates in all age categories, reaching 17-18%clinical pregnancy even in women ≧43 years. The AMH model furthersuggested that AMH at “best” levels facilitates pregnancy and deliverychances but at excessive levels appears associated with increasedmiscarriage risk.

These findings are entirely new and, indeed, inconsistent with currentteachings. For example, related art cited herein discloses higher AMHlevels, or in one case administrating AMH to increase levels, canpromote proper follicular development or other types of fertilitytreatment. The findings of this “best” AMH level and the risksassociated with excessive AMH levels are unexpected and new. Thefindings allow new and useful therapy with AMH to promote pregnancy,live birth and/or miscarriage rates through achieving and/or maintainingspecific levels in particular subjects.

Patients can be classified into good-, intermediate- and poor prognosiscategories based on clinical pregnancy and live birth rates, using onlyage and FOR parameters. AMH, in addition, depending on concentration,independently, also appears to control pregnancy, delivery chances aswell as pregnancy loss risk and, therefore, serves as a potentialtherapeutic agent.

Another aspect of the invention pertains to a method of diagnosingviability with in vitro fertilization. This method comprisesascertaining an AMH level of a subject from testing; and selecting oneof a plurality of prognosis categories that applies to the ascertainedAMH level by matching the ascertained AMH level with an applicable oneof a plurality of ranges of AMH levels pertaining to an age of thesubject. The plurality of prognosis categories are associated withspecific of the plurality of ranges of AHM levels and is selected fromthe group consisting of good, intermediate and poor prognosiscategories. The good prognosis category has a higher statistical chanceof pregnancy success with the in vitro fertilization than that of theintermediate and poor prognosis categories. The poor prognosis categoryhas a worse statistical chance of pregnancy success with the in vitrofertilization than that of the intermediate and good prognosiscategories. The intermediate prognosis category has a statistical chanceof pregnancy success with the in vitro fertilization that is betweenthat for the poor and good prognosis categories.

Yet another aspect of the invention relates to a method for terminatingpregnancy or increasing miscarriage rate in a subject, comprisingadministering to the subject an effective amount of AMH to achieve andmaintain an AMH level that is higher than that of (i) 7.0 ng/ml for thesubject being under 36 years old, and (ii) 6.5 ng/ml for the subjectbeing 36-42 years old inclusive.

Still another aspect of the invention relates to a method for decreasinga pregnancy rate in a subject, comprising administering to the subjectan effective amount of AMH to achieve and maintain an AMH level that ishigher than that of (i) 8.5 ng/ml for the subject being under 36 yearsold; (ii) 7.5 ng/ml for the subject being 36-38 years old inclusive;(iii) 7.0 ng/ml for the subject being 39-42 years old inclusive; and(iv) 7.5 ng/ml for the subject being over 42 years old.

BRIEF DESCRIPTION OF THE DRAWING

For a better understanding of the present invention, reference is madeto the following description and accompanying drawings, while the scopeof the invention is set forth in the appended claims.

FIG. 1A is a chart showing age-specific model of pregnancies based ongood quality embryos produced per cycle for clinical pregnancy rates.

FIG. 1B is pregnancy probability graph based on the content of the chartof FIG. 1A.

FIG. 1C is a chart showing age-specific model of live births based ongood quality embryos produced per cycle for live birth rates.

FIG. 1D is a live birth probability graph based on the content of thechart of FIG. 1C.

FIG. 2A is a chart showing age-specific model of pregnancies based onFSH levels (in mIU/ml) for clinical pregnancy rates.

FIG. 2B is pregnancy probability graph based on the content of the chartof FIG. 2A.

FIG. 2C is a chart showing age-specific model of live births based onFSH levels (in mIU/ml) for live birth rates.

FIG. 2D is a live birth probability graph based on the content of thechart of FIG. 2C.

FIG. 3A is a chart showing age-specific model of pregnancies based onAMH levels (in ng/ml) for clinical pregnancy rates.

FIG. 3B is pregnancy probability graph based on the content of the chartof FIG. 3 a.

FIG. 3C is a chart showing age-specific model of live births based onAMH levels (in ng/ml) for live birth rates.

FIG. 3D is a live birth probability graph based on the content of thechart of FIG. 3C.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

The present invention is based on our study that was initiated todetermine whether, even in a relatively adversely selected infertilepatient population, definitions of good-, intermediate- and poorprognosis can still be made in different age categories. Suchinformation would obviously be prospectively useful to patients planningto undergo IVF but, even retrospectively, would also allow for betterdefinitions of patient populations undergoing IVF and, therefore, forbetter outcome comparisons between centers. In the U.S., where, to allowfor such comparisons, national outcome reporting is legislativelymandated by Congress, the current system has recently been demonstratedto be inadequate and even misleading. Yet another reason for this studywas the recent recognition that effects of various IVF treatmentsgreatly vary between good-, intermediate- and poor-prognosis patients,and, indeed, may be outright harmful in the latter group.

This study, therefore, approached the issue differently thanconventional approaches by primarily assessing the impact of FOR on IVFoutcome in three distinctively different models: In a retroactive model,based on number of embryos produced in a given IVF cycle, and in twoprospective models, utilizing FOR's two most widely used laboratorysurrogates, FSH and AMH. While the prospective definition of prognosisof IVF patients has been a longstanding goal in the field with variousconventional models proposed, it is our assessment that none of thosevarious conventional models have been proven clinically effective sofar.

Patient Populations

This study involves three partially overlapping patient cohorts: CohortI, 1,247 consecutive fresh IVF cycles during 2009-2013, including eggdonor cycles, however excluding elective single embryo transfer (eSET)and mild stimulation cycles, was used to investigate associations ofgood quality embryo numbers (1-15) with clinical pregnancy and livebirth rates at different ages (<36, 36-38, 39-40, 41-42 and ≧43 years).Patients <36 are presented as a single age category because ages <30,31-32, 33-34 and 35-36 produced basically identical outcomes as graphedin FIGS. 1a -1 d.

Cohort II, 1514 consecutive fresh autologous non-donor IVF cycles,excluding eSET and mild stimulation cycles, was used to establishassociations of highest FSH levels (2.5-40.0 mIU/ml) with clinicalpregnancy and live birth rates, stratified for age.

Cohort III, 632 fresh autologous non-donor cycles between 2011-2014,excluding eSET and mild stimulation cycles, was used to assessassociations of lowest AMH levels (<0.5-10.0 ng/ml) with clinicalpregnancy and live birth rates, stratified for age. Only AMHmeasurements by the Beckman Generation 2 AMH assay were included.

All patient data were extracted from our center's anonymized electronicresearch data base, representing consecutive IVF cycles, unless meetingexclusion criteria noted above. Table 1 summarizes patient and IVF cyclecharacteristics for all three patient cohorts.

FSH and AMH Values

FSH values were ascertained in house by commercial assay. Again, asstated above, laboratory test procedures and equipment to ascertain anAMH level are conventionally known. For this study, AMH was assessedwith such Generation II (second generation) assays. Those skilled in theart will understand that other generations of assays and conventionaltest procedures could be used as well. Since earlier generation AMHassays deviate from the here utilized assay, values reported in thisstudy cannot be applied to other AMH assays at the very high or very lowranges; however, in mid-range, all AMH assays are very similar. As laterdemonstrated, mid-range values mattered most in this study. While AMHassays may vary at the extremes of very high or very low AMH levels,they are very similar in the medium and other ranges significant forthis invention and application.

IVF Cycle Protocols

Cycle stimulation protocols at our center are limited, and choice ofgonadotropin manufacturer is deferred to patients and their medicalinsurances. Oocyte donors receive a long agonist protocol (150-300 IU ofgonadotropins daily), usually given as human menopausal gonadotropin(hMG). Since most of our center's patients present with LFOR, a majorityreceive short microdose agonist protocols, with FSH (300-450 IU) and hMG(150 IU). Patients with normal FOR, if under age 38, receive similarstimulation to egg donors. Patients with LFOR are pretreated withdehydroepiandrosterone (DHEA) to raise testosterone levels to above 28ng/ml (lnmol/L) before IVF cycle start,18 and also receive CoQ10supplementation.19 Up to age 38, our center transfers in fresh cyclesonly 1-2 embryos; between ages 38-42, 3 embryos and above age 42, 3 tomaximally 5 embryos.

Embryo Assessment

Our center routinely transfers embryos on day-3 (cleavage stage) afterassessment and grading.20 Only 4-8-cell embryos on day-3 of at leastgrade 3 are transferred or cryopreserved and, therefore, considered goodquality.

Statistics

FOR parameters and categorical age were used to model the probability ofclinical pregnancy, live birth or pregnancy loss using logisticregression. For models with AMH, AMH2 was also included, and astatistically significant predictor of all outcomes. A P-value of <0.05was considered statistically significant. All statistical analyses werepreformed using SAS version 9.4 software.

Results

Effects of Embryo Numbers

Table 2 summarizes cycle characteristics for Cohort I. As expected, goodquality embryos, pregnancy and live birth rates declined with advancingage, while miscarriage rates increased.

How embryo numbers affected clinical pregnancy and live birth rates isshown in FIGS. 1a-1d : Good-, intermediate- and poor outcomes withineach age category were defined at break points of pregnancy and livebirth rates. In all figures, fields were colored in yellow for poorprognosis, in blue for good prognosis and left uncolored forintermediate-prognosis.

As FIGS. 1a and 1c demonstrate, at youngest age (<36 years) pregnancyand delivery rates were excellent almost independent of good qualityembryo numbers. Even poor prognosis patients (defined by only 1-3embryos) still achieved clinical pregnancy rates of 34-38% and livebirth rates of 29-32%. Both rates steadily increased with increasingembryo production to a maximum of 62% and 53%, respectively.

Because our center only rarely performs eSET,21 and up to age 38practically never transfers more than 2 embryos, this age category atmost received 2-embryo transfers (2 ETs). Yet, pregnancy and live birthrates increased almost linearly (FIGS. 1b and 1d ) with increasingembryo production.

The pregnancy loss rate, defined as clinical pregnancies minus livebirths, however remained similar, whether a woman produced 1 or 15embryos: Pregnancy loss <36 occurred in 14.7% of women with 1 embryo andin 14.5% of women with 15 embryos.

FIGS. 1a and 1c also demonstrate that, despite uniformly good clinicalpregnancy and live birth rates <36 years, separation of good-prognosis(≧51% clinical pregnancy and ≧44% live birth), intermediate prognosis(respectively 40-50% and 34-44%) and poor prognosis patients(respectively <39% and <33%) was still possible.

From age 36, outcomes started declining, while pregnancy lossesincreased, at age 36-38 reaching 29.2% for women who produced 1 and28.6% in those with 15 embryos. This traditional embryo qualityparameter, thus, remained stable (FIGS. 1a and 1c ) and almost linearimprovements of pregnancy and live birth rates with increasing embryoproduction was maintained into older ages (FIGS. 1b and 1d ). Indeed,improvements within age categories between 1 and 15 embryos grew withadvancing age: Under age 36, clinical pregnancy chances increased by82.4% (from 34% to 62%) but by 104.2% (from 24% to 49%) in age category36-38. Concomitantly, live birth rates improved by 89.3% (from 29% to53%) under age 36 and by 105.9% (from 17% to 35%) at ages 36-38. By age≧43, clinical pregnancy rate for 1 embryo was 6%, and for 15 embryos17%, a 183% increase, while live births increased from 3% to 8%, a166.7% increase (FIG. 1).

As FIGS. 1a and 1c demonstrate, with persistently decreasing clinicalpregnancy and live birth rates, women ≧43 years only with 7 or moreembryos reached 10% clinical pregnancy rates or higher, and even with upto 15 embryos remained in single digit range for live births. No womanin that age group, therefore, could be considered a good prognosispatient.

Increasingly, poor embryo quality with advancing female age was alsoreflected in increasing pregnancy loss, in women with 1 embryo reaching50.0% at age ≧43, and 52.9% with 15 embryos. The embryo qualityparameter of pregnancy loss, therefore, remained similar within agecategories,—even at most advanced age; yet, clinical pregnancy and livebirth rates within age categories improved with growing embryo numbersproduced, and did so more and more as women aged.

Even though embryo numbers transferred were similar within agecategories, pregnancy and live birth rates in each age category almostlinearly increased between 1-15 embryos with increasing embryoproduction. Concomitantly, pregnancy loss rates, defined as clinicalpregnancies minus live births, remained similar within age categories inembryo and FSH models, whether a woman produced 1 or 15 embryos. In theAMH model, pregnancy loss also remained stable within age categories atlow and intermediate (“best”) AMH levels but spiked in all agecategories at highest AMH levels.

Embryo quality has been strongly associated with pregnancy loss ratesbecause embryo aneuploidy is considered the by far most frequent causeof miscarriages. The whole concept of pre-implantation genetic diagnosis(PGS) is, indeed, based on this association and the consequential stepof attempting to eliminate aneuploid embryos prior to embryo transfer.

Our study, therefore, demonstrated that this aneuploidy-associateddefinition of embryo quality did not change with increasing embryoproduction within age categories, except at very high AMH levels; yet,increasing embryo production, independent of numbers of embryostransferred, still was strongly associated with improving clinicalpregnancy and live birth rates.

This previously unknown association, thus, establishes an additional,previously unknown embryo quality parameter, in itself stronglyassociated with increasing embryo numbers and, therefore, with improvingFOR.

The study also demonstrated that, again somewhat surprisingly, only atage 36 years outcomes started to decline with advancing age.Concomitantly, pregnancy loss also increased in parallel, reaching atleast 50% by age ≧43 years. Yet, within all age categories pregnancyloss remained the same independent of embryo numbers produced bypatients, except in the AMH model, where pregnancy loss spiked athighest AMH levels. In addition, at all ages relative IVF outcomeimprovements between 1 and 15 embryos actually expanded with advancingage.

This newly discovered embryo quality parameter, described above, thus,appears to gain in physiologic importance with advancing age.

Effects of FSH Levels

Table 2 describes cycle numbers, peak FSH levels and clinical pregnancyas well as live birth rates at different female ages.

FIGS. 2a-2d summarize probabilities of clinical pregnancies (FIGS. 2aand 2b ) and live births (FIGS. 2c and 2d ) at FSH levels between2.5-40.0 mIU/ml: Both at all ages declined with increasing FSH levels.Moreover, within each FSH category, both outcomes also declined withadvancing age. In all figures, fields were colored in yellow for poorprognosis, in blue for good prognosis and left uncolored forintermediate-prognosis.

For women <36 years, FSH only up to 7.5 mIU/ml denoted good prognosis(pregnancy 36-43%; live birth 30-36%). FSH levels mattered at all ages,with lower FSH levels, even with good-prognosis and within normal FSHlevels offering better outcomes. Pregnancy after age 40, and live birthseven as early as age 36, failed to reach good-prognosis at even lowestFSH, suggesting that, at least in adversely selected patients, normalFSH levels may have to be reconsidered.

FSH changed in its clinical relevance with advancing female age: Forexample, an FSH of 22.5-25.0 mIU/ml<36 years resulted in clinicalpregnancy in 19%; though at age 41-42, the same rate required an FSH of2.5 mIU/ml (FIG. 2a ); FSH of 32.5 mIU/ml<36 years, allowed live birthsin 11%; but at 41-42, this live birth rate required an FSH of 2.5 mIU/ml(FIG. 2c ).

FIGS. 2a-2d also demonstrate that ≧43 years treatment futility,according to the American Society for Reproductive Medicine (ASRM) atca. 1% live birth rate,22 was reached at FSH 22.5 mIU/ml. Yet, up to 42years, even up to FSH 40.0 mIU/ml futility was avoided.

Observed FSH dynamics, in contrast, did not surprise: as expected, withincreasing FSH levels clinical pregnancy and live birth rates declinedat all ages. Moreover, the same was true with advancing age within eachFSH category. FSH levels, thus, mattered at all ages, with lower FSHlevels, even within what is widely perceived a normal FSH range,offering better outcomes. These data reemphasize the importance ofassessing patients with age-specific FSH levels.

Effects of AMH Levels

Table 2 also introduces Cohort III, which was used to assessassociations of lowest AMH (between >0.5 ng/ml and 10.0 ng/ml) withpregnancy (FIGS. 3a and 3b ) and live birth rates (FIGS. 3c and 3d ). Incontrast to embryo and FSH models, pregnancy and live birth chances inassociation with AMH followed a bell-shaped curve, with best outcomes atmidrange.

The very high pregnancy and live birth rates at “best” AMH levels wereunexpected: Under age 36, AMH values between 3.5 ng/ml and 8.5 ng/mloffered best pregnancy chances (49-55%, good-prognosis patients);1.0-3.0 ng/ml, and 9.0-10.0 ng/ml offered intermediate-prognoses(pregnancy 33-46%), and only AMH 0.5 ng/ml poor prognosis (pregnancyrate of 29%, FIG. 3a ).

Live births behaved similarly: Best live birth rates (43-47%) wereobtained at AMH 3.5-7.0 ng/ml; intermediate rates (32-41%) at AMH of1.5-3.0 ng/ml and 7.5-9.0 ng/ml. Even poor prognosis at AMH of 1.0 ng/mlstill was associated with 25-29% live births.

Clinical pregnancy and live birth declined only mildly up to age 42, andan unexpectedly high 18% pregnancy rate was still achieved ≧43. Livebirths reached a respectable 7% (oldest conception at age 47).Pregnancies in single digits occurred only with AMH <1.5 ng/ml. WithAMH >2.0 ng/ml, clinical pregnancy rates were between 10-18%, thoughdeclined at very high AMH (FIG. 3a ) after reaching peak pregnancy ratesat AMH 5.5-6.5 ng/ml. This patient group, however, also experienced thehighest pregnancy loss rate of any model.

Pregnancy loss at all ages remained similar for low and “best” AMHlevels but significantly increased at highest AMH levels: <36 years, atAMH 0.5 ng/ml only 13.8% miscarried and at “best” level of 5.5 ng/mlonly 13.0%; but at AMH of 10.0 ng/ml, rates spiked to 42.9%. The sameoccurred ≧43, where pregnancy loss was 57.1% with lowest AMH, 61.1% at“best” AMH levels and spiked to 81.8% at highest AMH, contradicting thatAMH linearly reflects not only oocyte quantity but also quality.23

The most consequential findings of this study, however, relate to AMHlevels: While in embryo and FSH models relationships were almost linear,clinical pregnancy and live birth chances in relation to AMH levelsfollowed a bell-shaped curve, with maximal clinical pregnancy and livebirth chances at midrange AMH, rather than at highest or lowest levels.

This model, indeed, demonstrated unexpectedly high pregnancy rates at“best” AMH levels even into oldest age categories. Live birth ratesbehaved similarly and were up to age 42 remarkably high. Even at “best”AMH levels, beyond age 42 extremely high rates of pregnancy loss were,however, observed. Women ≧43, at “best” AMH levels, for example, reachedan almost incredulous 18% clinical pregnancy rate but only a 7% livebirth rate, representing a 61.1% clinical miscarriage rate. While a livebirth rate of 7% in this age category has still to be consideredremarkable, the rate of observed pregnancy loss is even more so.

While in embryo and FSH models pregnancy loss rates remained the samewithin age categories independent of embryo numbers and FSH levels, wenoted earlier that in the AMH model in all age categories miscarriagerates only remained similar at low and “best” AMH levels but spikedsignificantly at highest AMH levels. In the oldest age category ≧43years, pregnancy loss reached 57.1% in women with 1 embryo, 61.1% at“best” AMH levels and, indeed, spiked to 81.8% at highest AMH levels.

Combined, all of these findings strongly suggest favorableAMH-associated effects on clinical pregnancy in association with IVFespecially at good and “best” AMH levels, and unfavorable effects inassociation with increasing miscarriages with highest AMH levels. Theseobservations, therefore, contradict the widely expressed belief that AMHvalues linearly reflect not only oocyte quantity but also quality

Statistical Comments

Because all three here utilized statistical models highly correlate inrepresentation of FOR in association with patient age, construction ofcombined statistical models was not feasible. In univariate models, FSHand AMH, independently, were not predictive of miscarriage. Embryonumbers, however, did reach significance in an univariate model(P=0.008), though, as expected, significance was lost with adjustmentsfor age, as embryo numbers in themselves are age-dependent. Table 1.Patient characteristics of patient Cohorts I, II and III

Findings

This study was initiated to determine whether it was possible in asomewhat adversely selected infertile patient population to reachdefinitions of good-intermediate- and poor prognosis in different agecategories based on clinical pregnancy and live birth rates.Surprisingly, age-specific investigations of clinical pregnancy and livebirth rates in IVF via here presented three distinct outcome modelsrevealed previously unknown insights into physiological processes thatfavor clinical pregnancy chances and miscarriage risk in associationwith IVF.

As expected, defining parameters for individual prognosis categorieschanged with advancing female age, and required increasing embryonumbers to maintain designations. With clinical pregnancy as finaloutcome, women ≧43 years no longer demonstrated what could be defined asgood prognoses. With live birth as final outcome, all women in that agecategory demonstrated, indeed, poor prognosis.

Utilizing peak FSH levels as FOR surrogate, similar associations becameapparent (FIG. 2): Pregnancy and live birth rates declined withincreasing FSH and advancing age. Again, prognoses could be definedbased on cut offs in pregnancy and live birth rates. This model,however, already at young ages revealed a surprisingly narrow range ofgood-prognosis: In women <36 years, only FSH <7.5 mIU·mL, and at ages36-37, only FSH <2.5 mIU/ml qualified with reference point pregnancy asgood-prognosis, while with end point live birth, only age <36 qualified.Even intermediate-prognosis became rare after age 40, and required FSHlevels <5.0 mIU/ml, while only poor-prognosis patients were left ≧43years.

These data confirm the importance of utilization age-specific FSH levelsin assessing infertile women.

Somewhat surprising observations were made in the AMH model: In contrastto the two previously discussed embryo and FSH models, it demonstrated atypical bell-shaped polynomial pattern. In all figures, fields werecolored in yellow for poor prognosis, in blue for good prognosis andleft uncolored for intermediate-prognosis. Worst IVF outcomes wereobserved at AMH extremes; “best” AMH was slightly above mid-point (FIGS.3a-d ). In pregnancy rates this pattern carried over into the oldestpatient category (FIG. 3a ), though based on live births, no goodprognosis patients were found ≧43 years (FIG. 3c ).

Here reported outcomes are, of course, not automatically applicable toother IVF programs. They were results of very specific practicepatterns.18, 25 Even assuming identical patient populations (in itselfalso a highly unlikely proposition), different clinical protocols atother centers will result in different pregnancy and live birth rates.To construct universally applicable models, this study will have to berepeated on a multicenter or even national basis, and further validatedagainst results from IVF centers with varying patient populations andtreatment protocols.

Different AMH assays utilized by IVF centers may also offer mildlyvarying results, 26 though mid-range AMH, in this study demonstrated tobe most important AMH range, demonstrates least discrepancies betweencurrently used AMH assays.

Relevance of Treatment Protocols

Reliable prognostication of patients is of potential clinicalimportance: Treatments, which recently entered routine IVF, have shownvarying effectiveness in different patient categories. For example, theconcept of embryo selection in all of its applications appearsbeneficial only in good-prognosis patients. With intermediate-prognosis,embryo selection appears ineffective, while with poor prognosis itoutright decreases pregnancy and live birth chances.4 At the otherextreme, treatments reported effective in adversely selected patients18,19, 25 may be ineffective in intermediate and good prognosis patients.

IVF protocols, therefore, have to evolve toward individualization ofcare, and a reproducible classification of patients, as here presented,would greatly contribute to standardization of individualized treatmentoptions.

Unanticipated Finding

An unanticipated finding from the study concerns a previously unknownembryo quality parameter, apparently closely associated with AMH. Theparameter appears to increase in physiologic importance with advancingfemale age. This finding raises the possibility of using AMH as apotential therapeutic drug in affecting infertility treatment outcomes.

The most unexpected findings of this study were counterintuitive, and insome aspects contradictive to currently prevailing opinions. Forexample, current consensus holds that egg/embryo quantity and qualityrun in parallel; as quantity declines with advancing age, so doesquality.

Assuming this to be correct, one would expect declining embryo qualitywithin age categories, with best pregnancy rates occurring in women withhighest embryo production. With clinical pregnancy and live birth ratesin every age category increasing in parallel with increasing embryonumbers, this, indeed, on first glance appeared to be the case. Closeranalysis, however, revealed that observed outcome improvements, likely,did not reflect improving traditional embryo quality since in each agecategory the rate of spontaneous pregnancy loss (i.e., the differencebetween clinical pregnancy and live birth rates) remainedconstant,—whether a patient produced 1 or 15 embryos. What has beentraditionally perceived as a major component of embryo quality,therefore, apparently does not change with increasing embryo production.

Yet, as expected, pregnancy loss rates, reflecting this traditionallyembryo quality parameter, still did increase with advancing agecategories.

The embryo's chromosomal constitution, widely accepted as a principalindicator of traditional embryo quality, and the theoretical basis ofPGS1, therefore, does not appear involved in the observed IVF outcomeimprovements within age categories with increasing embryo numbers. Thequestion, therefore, is what drives this new observation?

It obviously has to be another, non-chromosomal component of embryoquality, which, based on here presented data, increases with increasingembryo numbers. In trying to ascertain potential associations, weconsidered the possibility that co-culture of multiple embryos may havebeneficial effects on implantation but dismissed this explanation sinceour laboratory at most co-cultures only three to four embryos in onedish. Co-culture of embryos, therefore, could not explain the almostlinear increase in clinical pregnancy and live birth rates up to 15embryos within age categories.

FOR, thus, appears defined by more than just age since quantity ofoocytes/embryos, in themselves, appears to reflect the embryos' abilityto implant and lead to clinical pregnancy, independent of traditionalembryo quality parameters, like aneuploidy.

This, in itself, is a potentially important finding, and may, at leastpartially explain why the concentration on ploidy in defining embryoquality through utilization of the PGS procedure has so far failed toimprove IVF outcomes contrary to most predictions.6,7

Here presented data suggest that a major second factor affects embryoquality, and with advancing age assumes increasing importance for theestablishment of pregnancy in association with IVF.

This second factor is, of course, still unknown but lends itself tospeculations: It must be associated with increasing oocyte/embryoproduction in IVF cycles; yet, since observed improvements withincreasing embryo numbers almost doubled between youngest and oldest agecategories, its efficacy must increase with advancing female age.

AMH is, of course, strongly associated with oocyte/embryo production inIVF. At “best” AMH levels, our third model demonstrated extraordinarilyhigh clinical pregnancy rates into even the oldest age categories. Womenat ages 41-42 years achieved clinical pregnancy rates of 29-30%, and of17-18% even at ages 43 and above. Neither embryo nor FSH models,however, demonstrated such extraordinary clinical outcomes at advancedage categories.

One, therefore, can further hypothesize that these extraordinaryoutcomes relate to “best” AMH levels, which in this study were definedat ranges of 3.5-8.5 ng/ml in the youngest, and in a somewhat narrowerrange between 4.5-7.5 ng/ml in the oldest age categories. Even oldestwomen with AMH in “best” range still experienced extraordinarily highclinical pregnancy chances of 17-18%.

Yet, this apparently beneficial AMH-associated effect on clinicalpregnancy rates was mostly lost to high miscarriage rates and, thereforenot reflected in equally high live birth rates. While live birth ratesremained relatively high until age 42, at or above age 43, live birthrates at “best” AMH levels, though still higher (6-7%) than at very lowor very high AMH levels (2-5%), had lost significant ground.

Combined, these observations, however, support the very interestinghypothesis that AMH effects on clinical IVF outcomes aredosage-dependent: At all ages, AMH at “best” levels (or anAMH-associated factor) improved the ability of embryos to implant,leading to quite extraordinarily high clinical pregnancy rates. Whetherthis represents an AMH effect on oocytes, embryos or the endometriumremains to be determined.

At very high levels, AMH, however, is also associated with increasedpregnancy loss. This conclusion is supported by the here reportedobservation that pregnancy loss in all age categories spikes at veryhigh AMH levels, in the oldest age category ≧43 years reaching as highas 81.8%, while at low and “best” levels being only around 60% even inthis oldest patient category.

Here reported observations, therefore, support the hypothesis that AMH(or an AMH-associated factor) plays an undefined favorable modulatoryrole at “best” levels in establishing pregnancies in association withIVF. Excessively high levels, however, lead to pregnancy loss. Therelative importance of this AMH-associated effects increases withadvancing female age, which may suggest a potential therapeutic role forAMH at appropriate dosages in improving clinical outcomes in IVF,especially in older women.

Preferably, the protocol for manufacturing recombinant AMH or purifyingit is in the TGF-beta superfamily and there are other compounds in thisfamily that have been manufactured for human use. Also there are severalcompanies that manufacture it for research purposes, as exemplifiedbelow, but no one that makes it for human use yet.

The protocol may be expressed in CHO cells prior to human use. CHO cellsare a laboratory-cultured cell line derived from cells from the ovariesof Chinese hamsters. Chinese hamsters are a popular laboratory mammal,partially due to their small size and low chromosome number, which makesthem a good model for tissue culture and radiation studies. They are acommonly-used mammalian cell model used in biology and in medical andpharmaceutical research. In addition, they are frequently used forcommercial purposes to manufacture therapeutic recombinant proteins.

R&D Systems—Recombinant Human MIS/AMH Proteinhttps://www.rndsystems.com/products/recombinant-human-mis-amh-protein1737-ms

OriGene—AMH (NM 000479) Purified Human Protein, Catalog # TP308397http://www.origene.com/protein/TP308397.aspx

abm—AMH Recombinant Proteinhttps://www.abmgood.com/AMH-Recombinant-Protein-AMH.html

MyBiosource—AMH recombinant protein: Anti-Mullerian Hormone (AMH)Recombinant Protein, Catalog # MB 52010947http://www.mybiosource.com/prods/Recombinant-Protein/Anti-Mullerian-Hormone-AMH/AMH/datasheet.php?products_id=2010947

The contents of U.S. provisional patent application No. 62/128,127 areincorporated herein by reference as concerns the contents under theDescription on pages 18-65, inclusive in particular of the discussionunder the heading “Compositions” on page 21, “Peptides” on pages 21-30,“Nucleic Acids and Vectors” on pages 31-40, “Treatment Methods” on pages40-43, “Pharmaceutical Compositions and Formulations” on pages 43-56,“Administration/Dosing” on pages 56-61, “Routes of Administration” onpages 61-65, and “Vaginal Administration” on pages 65-66. Themanufacture of a composition containing AMH that is described isapplicable for use with the present invention and its delivery methodand dosages are applicable as well, except that the amount administeredover time in accordance with the invention varies, dependent upon theage of the subject, in a manner that either:

-   -   achieves and maintains the patient AMH level within confines of        the probability bell curves of FIG. 3A or FIG. 3C as applicable        to increase the probability, or    -   achieves and maintains the patient AMH level outside confines of        the probability bell curves of FIG. 3A or FIG. 3C as applicable        to decrease the probability.

The confines of the bell curve of FIG. 3B pertain to pregnancyprobability of the subject and the confines of the bell curve of FIG. 3Dpertain to live birth probability of the subject. The bell curvesrepresent statistical chance of success for pregnancy in the case ofFIG. 3B as tabulated in FIG. 3A and the statistical chance for successof live birth in the case of FIG. 3D as tabulated in FIG. 3C.

The AMH levels for good, intermediate and poor pregnancy probability arein FIG. 3B (set forth as AMH level ranges for subject age ranges) andfor good, intermediate and poor live birth probability are in FIG. 3C(set forth as AMH level ranges for subject age ranges). The AMH levelsof FIGS. 3A and 3C are readily entered, stored and categorized inmachine readable media, such as a computer memory, into different rangesof AMH levels corresponding to either good, intermediate or poorprognosis categories with respect to being a viable candidate for invitro fertilization for the different age ranges.

In this application, the concept of categorizing ranges of AMH levelsinto good, intermediate and poor prognosis categories according tosubject age is intended to encompass either display of any of FIGS.3A-3D (that indicate the categories) or accessing from computer memorystored AMH level data from any of FIGS. 3A-3D in a manner thatcategorizes the stored data into the prognosis categories.

The AMH level for a subject can be ascertained through conventionaltesting. Once the AMH level is known, it is a simple matter to match theage of the subject with the applicable one of the different age rangesfor which the AMH levels are categorized and to match the ascertainedAMH level with an applicable one of the ranges of AMH levels thatcorrespond to the good, intermediate and poor prognosis categories. Suchmatching can be used to determine whether the subject is viable as acandidate for in vitro fertilization with respect to pregnancyprobability, live birth probability or both.

The bell curve of FIG. 3B in view of the tabulated AMH levels set forthin FIG. 3A indicates categories, which pertain to the viability of acandidate for in vitro fertilization with respect to pregnancyprobability, namely, a good prognosis group, an intermediate prognosiscategory and a poor prognosis group.

The good prognosis category that pertains to pregnancy probability is inaccord with AMH level ranges of only:

3.5 to 8.5 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is under 36 years old,

4.5 to 7.5 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is 36 to 38 years old inclusive,

5.0 to 7.0 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is 39 to 42 years old inclusive, and

4.5 to 7.5 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is over 42 years old.

The intermediate prognosis category that pertains to pregnancyprobability is in accord with any of AMH level ranges of only:

1.0 to 3.0 ng/ml inclusive and 9.0 to 10.0 ng/ml inclusive encompassingthe ascertained AMH level for the subject that is under 36 years old,

2.5 to 4.0 ng/ml inclusive and 8.0 to 10.0 ng/ml inclusive encompassingthe ascertained AMH level for the subject that is 36 to 38 years oldinclusive,

1.5 to 4.5 ng/ml inclusive and 7.5 to 10.0 ng/ml inclusive encompassingthe ascertained AMH level for the subject that is 39 to 40 years oldinclusive,

2.5 to 4.5 ng/ml inclusive and 7.5 to 10.0 ng/ml encompassing theascertained AMH level for the subject that is 41 to 42 years oldinclusive, and

3.0 to 4.0 ng/ml inclusive and 8.0 to 10.0 ng/ml inclusive encompassingthe ascertained AMH level for the subject that is over 42 years old.

The poor prognosis category that pertains to pregnancy probability is inaccord with AMH level ranges of only:

0.0 to 0.5 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is under 36 years old,

0.0 to 2.0 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is 36 to 38 years old inclusive,

0.0 to 1.0 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is 39 to 40 years old inclusive,

0.0 to 2.0 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is 41 to 42 years old inclusive,

0.0 to 2.5 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is over 42 years old.

Based on FIGS. 3C and 3D, one can observe that the good prognosiscategory for live birth probability arises in accord with:

5.0-6.5 ng/ml inclusive for the subject who is between 39-42 years old,

4.5-6.5 ng/ml inclusive for the subject who is between 36-28 years old,and

3.5-7.0 ng/ml for the subject who is under 36 years old.

However, after comparing FIGS. 3A and 3B with FIGS. 3B and 3D, one canrecognize the full extent of AMH levels in each of the good,intermediate, poor prognosis groups are not the same as between clinicalpregnancy rates and pregnancy probability versus live birth rates andlive birth probability. That is, some of the AMH levels overlap and somedo not for each of the good, intermediate and poor categories.

One can identify the AMH levels that overlap each other for the goodprognosis categories for both pregnancy probability and live birthprobability. The non-overlapping portions that were considered goodprognosis for one or the other can be considered instead as intermediateprognosis for both. One can also identify the AMH levels that overlapeach other for the intermediate prognosis categories for both pregnancyprobability and live birth probability. The non-overlapping portionsthat were considered intermediate prognosis for one or the other can beconsidered instead poor prognosis for both. The following identifiesspecific values from the AMH level ranges obtained from a conventionalGeneration II (second generation) assay, but similar values of AMH,obtained by other AMH assays, are encompassed by the present invention.

The good prognosis category pertains to both pregnancy probability andlive birth probability and is in accord with AMH level ranges of:

3.5 to 7.0 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is under 36 years old,

4.5 to 6.5 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is 36 to 38 years old inclusive, and

5.0 to 6.5 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is 39 to 42 years old inclusive.

Also, the intermediate prognosis category pertains to both pregnancyprobability and live birth probability and is in accord with AMH levelranges of:

1.5 to 3.0 ng/ml inclusive and 7.5 to 9.0 ng/ml inclusive encompassingthe ascertained AMH level for the subject that is under 36 years old,

2.5 to 4.0 ng/ml inclusive and 7.0 to 8.5 ng/ml inclusive encompassingthe ascertained AMH level for the subject that is 36 to 38 years oldinclusive,

2.0 to 4.5 ng/ml inclusive and 7.0 to 8.5 ng/ml inclusive encompassingthe ascertained AMH level for the subject that is 39 to 40 years oldinclusive, and

2.0 to 4.5 ng/ml inclusive and 7.0 to 8.5 ng/ml encompassing theascertained AMH level for the subject that is 41 to 42 years oldinclusive.

Further, the poor prognosis category pertains to both pregnancyprobability and live birth probability and is in accord with AMH levelranges of:

0.0 to 1.0 ng/ml inclusive and 9.5 to 10.0 ng/ml inclusive encompassingthe ascertained AMH level for the subject that is under 36 years old,

0.0 to 2.0 ng/ml inclusive and 9.0 to 10.0 ng/ml inclusive encompassingthe ascertained AMH level for the subject that is 36 to 38 years oldinclusive,

0.0 to 1.5 ng/ml inclusive and 9.0 to 10.0 ng/ml inclusive encompassingthe ascertained AMH level for the subject that is 39 to 42 years oldinclusive, and

0.0 to 10.0 ng/ml inclusive encompassing the ascertained AMH level forthe subject that is over 42 years old.

In addition, the invention has applicability to the use of AMHantagonists having the opposite effects (i.e., AMH receptor blockingantibodies, AMH binding antibodies etc.). For example, using AMHantagonists for induction of ovulation in Polycystic Ovary (PCO)syndrome patients who have abnormally high serum AMH levels. Also, AMHmay inhibit growth of some cancers including ovarian and prostate.

The present invention encompasses treatment of any species of subject,including, but not limited to humans and other primates, mammalsincluding commercial relevant mammals such as cattle, pigs, horses,sheep, cats, dogs, rats, and mice.

While the foregoing description and drawings represent the preferredembodiments of the present invention, it will be understood that variouschanges and modifications may be made without departing from the scopeof the present invention.

TABLE 1 Patient characteristics of patient Cohorts I, II and III CohortI Cohort II Cohort III Cycles (n) 1247 1514 632 Embryos (n) 4.9 ± 4.34.0 ± 3.4 4.1 ± 3.5 Age (years) 37.8 ± 6.7  39.5 ± 5.0  39.5 ± 4.9  FSH(mIU/ml) 17.3 ± 19.1 15.4 ± 14.8 15.8 ± 16.2 AMH (ng/ml) 1.1 ± 1.9 1.1 ±1.9 1.1 ± 1.9 Pregnancies (n) 346 246 106 (%) 27.8 16.2 16.8 Live births(n) 264 178 73 (%) 21.2 11.8 11.6 Miscarriages (n) 82 68 33 (%) 23.727.6 31.1

TABLE 2 Cohorts I, II and III: Patient characteristics by age categoryAges (years) <36 36-38 39-40 41-42 ≧43 COHORT I Cycles (n) 432 174 162183 296 Embryos (n) 7.5 ± 5.1 3.7 ± 2.9 3.7 ± 2.9 3.3 ± 2.4 3.1 ± 2.2Pregnancies (n) 203 49 40 32 22 (%) 47.0% 28.2% 24.7% 17.5% 7.4% Livebirths (n) 173 34 29 18 10 (%) 40.0% 19.5% 17.9% 9.8% 3.4% Miscarriages(n) 30 15 11 14 12 (%) 14.8% 30.6% 27.8% 43.8% 54.6% COHORT II Cycles(n) 303 234 239 259 479 FSH (mIU/ml) 11.8 ± 12.7 15.0 ± 14.1 15.5 ± 13.214.7 ± 14.2 18.0 ± 16.9 Pregnancies (n) 101 50 40 32 23 (%) 33.3% 21.4%16.7% 12.4% 4.8% Live births (n) 86 35 29 18 10 (%) 28.4% 15.0% 12.1%6.9% 2.1% Miscarriages (n) 15 15 11 14 13 (%) 14.9% 30.0% 27.5% 43.8%56.5% COHORT III Cycles (n) 127 87 103 109 206 AMH (ng/ml) 2.3 ± 3.3 1.1± 1.9 0.7 ± 1.0 0.6 ± 1.1 0.7 ± 0.7 Pregnancies (n) 45 16 16 14 15 (%)35.4% 18.4% 15.5% 12.8% 7.3% Live births (n) 37 11 13 7 5 (%) 29.1%12.6% 12.6% 6.4% 2.4% Miscarriages (n) 8 5 3 7 10 (%) 17.8% 31.2% 18.8%50.0% 66.7%

What is claimed is:
 1. A method of diagnosing a subject's probability ofpregnancy success with in vitro fertilization, comprising: ascertainingan anti-Müllerian hormone (AMH) level of the subject from testing; andselecting one of a plurality of prognosis categories that applies to theascertained AMH level by matching the ascertained AMH level with anapplicable one of a plurality of ranges of AMH levels pertaining to anage of the subject, wherein each of the plurality of prognosiscategories has an associated one of the plurality of ranges of AHMlevels and is selected from the group consisting of good, intermediateand poor prognosis categories, wherein: the good prognosis category hasa higher probability of pregnancy success with in vitro fertilizationthan that of the intermediate and poor prognosis categories, the poorprognosis category has a worse probability of pregnancy success with invitro fertilization than that of the intermediate and good prognosiscategories, and the intermediate prognosis category has a probability ofpregnancy success with in vitro fertilization that is between that forthe poor and good prognosis categories.
 2. The method of claim 1,wherein the good prognosis category pertains to pregnancy probabilityand is in accord with AMH level ranges of: 3.5 to 8.5 ng/ml inclusiveencompassing the ascertained AMH level for the subject that is under 36years old, 4.5 to 7.5 ng/ml inclusive encompassing the ascertained AMHlevel for the subject that is 36 to 38 years old inclusive, 5.0 to 7.0ng/ml inclusive encompassing the ascertained AMH level for the subjectthat is 39 to 42 years old inclusive, and 4.5 to 7.5 ng/ml inclusiveencompassing the ascertained AMH level for the subject that is over 42years old.
 3. The method of claim 1, wherein the intermediate prognosiscategory pertains to pregnancy probability and is in accord with any ofAMH level ranges of only: 1.0 to 3.0 ng/ml inclusive and 9.0 to 10.0ng/ml inclusive encompassing the ascertained AMH level for the subjectthat is under 36 years old, 2.5 to 4.0 ng/ml inclusive and 8.0 to 10.0ng/ml inclusive encompassing the ascertained AMH level for the subjectthat is 36 to 38 years old inclusive, 1.5 to 4.5 ng/ml inclusive and 7.5to 10.0 ng/ml inclusive encompassing the ascertained AMH level for thesubject that is 39 to 40 years old inclusive, 2.5 to 4.5 ng/ml inclusiveand 7.5 to 10.0 ng/ml encompassing the ascertained AMH level for thesubject that is 41 to 42 years old inclusive, and 3.0 to 4.0 ng/mlinclusive and 8.0 to 10.0 ng/ml inclusive encompassing the ascertainedAMH level for the subject that is over 42 years old.
 4. The method ofclaim 1, wherein the poor prognosis category pertains to pregnancyprobability and is in accord with AMH level ranges of: 0.0 to 0.5 ng/mlinclusive encompassing the ascertained AMH level for the subject that isunder 36 years old, 0.0 to 2.0 ng/ml inclusive encompassing theascertained AMH level for the subject that is 36 to 38 years oldinclusive, 0.0 to 1.0 ng/ml inclusive encompassing the ascertained AMHlevel for the subject that is 39 to 40 years old inclusive, 0.0 to 2.0ng/ml inclusive encompassing the ascertained AMH level for the subjectthat is 41 to 42 years old inclusive, 0.0 to 2.5 ng/ml inclusiveencompassing the ascertained AMH level for the subject that is over 42years old.
 5. The method of claim 5, wherein the good prognosis categorypertains to both pregnancy probability and live birth probability and isin accord with AMH level ranges of: 3.5 to 7.0 ng/ml inclusiveencompassing the ascertained AMH level for the subject that is under 36years old, 4.5 to 6.5 ng/ml inclusive encompassing the ascertained AMHlevel for the subject that is 36 to 38 years old inclusive, and 5.0 to6.5 ng/ml inclusive encompassing the ascertained AMH level for thesubject that is 39 to 42 years old inclusive.
 6. The method of claim 1,wherein the intermediate prognosis category pertains to both pregnancyprobability and live birth probability and is in accord with AMH levelranges of: 1.5 to 3.0 ng/ml inclusive and 7.5 to 9.0 ng/ml inclusiveencompassing the ascertained AMH level for the subject that is under 36years old, 2.5 to 4.0 ng/ml inclusive and 7.0 to 8.5 ng/ml inclusiveencompassing the ascertained AMH level for the subject that is 36 to 38years old inclusive, 2.0 to 4.5 ng/ml inclusive and 7.0 to 8.5 ng/mlinclusive encompassing the ascertained AMH level for the subject that is39 to 40 years old inclusive, and 2.0 to 4.5 ng/ml inclusive and 7.0 to8.5 ng/ml encompassing the ascertained AMH level for the subject that is41 to 42 years old inclusive.
 7. The method of claim 1, wherein the poorprognosis category pertains to both pregnancy probability and live birthprobability and is in accord with AMH level ranges of: 0.0 to 1.0 ng/mlinclusive and 9.5 to 10.0 ng/ml inclusive encompassing the ascertainedAMH level for the subject that is under 36 years old, 0.0 to 2.0 ng/mlinclusive and 9.0 to 10.0 ng/ml inclusive encompassing the ascertainedAMH level for the subject that is 36 to 38 years old inclusive, 0.0 to1.5 ng/ml inclusive and 9.0 to 10.0 ng/ml inclusive encompassing theascertained AMH level for the subject that is 39 to 42 years oldinclusive, and 0.0 to 10.0 ng/ml inclusive encompassing the ascertainedAMH level for the subject that is over 42 years old.
 8. The method ofclaim 1, in combination with increasing a pregnancy rate in the subject,comprising administering to the subject an effective amount of AMH toachieve and maintain the AMH level of between 3.5-8.5 ng/ml within thesubject.
 9. The method of claim 8, wherein the administering occurs fora period of time and with dosages, the period of time being selectedfrom the category consisting of about 1 day to about 180 days, 10 daysto about 120 days and 30 days to about 90 days, the dosages being withina range selected from the category consisting of about 100 ng per day toabout 44,000 ng per day, and about 22,000 ng per day to about 44,000 ngper day.
 10. The method of claim 8, further comprising: ceasing theadministrating after a period of time; inducing superovulation in thesubject after the period of time ends; and resuming the administratingas warranted to maintain the AMH level after a further period of timeelapses subsequent to the commencement of the inducing.
 11. The methodof claim 10, wherein the inducing superovulation in the subject iscarried out by administering to the subject at least one administrationselected from the category consisting of gonadotropin, folliclestimulating hormone (FSH), luteinizing hormone (LH), clomiphene, aselective estrogen-receptor modulator (SERM) and an aromatase inhibitor.12. The method of claim 8, wherein the administering to the subject aneffective amount of AMH to achieve and maintain the AMH level is withina range in accord with: 3.5-8.5 ng/ml for the subject being under 36years old; 4.5-7.5 ng/ml for the subject being 36-38 years oldinclusive; 5.0-7.0 ng/ml for the subject being 39-42 years oldinclusive; and 4.5-7.5 ng/ml for the subject being over 42 years old.13. The method of claim 8, further comprising adjusting, over time, theeffective amount of AMH being administered accordingly to maintain theAMH level of between 3.5-8.5 ng/ml within the subject through testing ofthe AMH level of the patient over time.
 14. The method of claim 8 incombination with increasing a live birth rate in the subject, furthercomprising administering to the subject an effective amount of AMH toachieve and maintain the AMH level over time of between: 5.0-6.5 ng/mlinclusive for the subject who is between 39-42 years old, 4.5-6.5 ng/mlinclusive for the subject who is between 36-38 years old, and 3.5-7.0ng/ml for the subject who is under 36 years old.
 15. The method of claim1 in combination with increasing a live birth rate in a subject,comprising administering to the subject an effective amount of AMH toachieve and maintain an AMH level within a range in accord with: 3.5-7.0ng/ml for the subject being under 36 years old; and 4.0-6.5 ng/ml forthe subject being 36-42 years old inclusive.
 16. The method of claim 15,wherein the administering occurs for a period of time and with dosages,the period of time being selected from the group consisting of about 1day to about 180 days, 10 days to about 120 days and 30 days to about 90days, the dosages being within a range selected from the groupconsisting of about 100 ng per day to about 44,000 ng per day, and about22,000 ng per day to about 44,000 ng per day.
 17. A method forterminating pregnancy or increasing miscarriage rate in a subject,comprising: administering to the subject an effective amount ofanti-Müllerian hormone (AMH) to achieve and maintain an AMH level thatis higher than that of: 7.0 ng/ml for the subject being under 36 yearsold; and 6.5 ng/ml for the subject being 36-42 years old inclusive. 18.A method for decreasing a pregnancy rate in a subject, comprising:administering to the subject an effective amount of anti-Müllerianhormone (AMH) to achieve and maintain an AMH level that is higher thanthat of: 8.5 ng/ml for the subject being under 36 years old; 7.5 ng/mlfor the subject being 36-38 years old inclusive; 7.0 ng/ml for thesubject being 39-42 years old inclusive; and 7.5 ng/ml for the subjectbeing over 42 years old.